Stanley Post Acute

Inspectors wroteBased on interview and record review it was determined the facility failed to implement care plan interventions to prevent a fall for 1 of 3 sampled residents (#2) reviewed for falls. As a result, Resident 2 suffered bilateral femur fractures.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to use appropriate disinfection practices for reusable medical equipment, failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident use, and failed to ensure hand hygiene was completed for 1 of 4 halls reviewed for infection control and meal service, and 1 of 1 sampled resident (#44) reviewed during medication pass. This placed all residents who required CBG checks at risk for exposure to infections including bloodborne illness and placed residents at risk for cross contamination.

Inspectors wroteBased on interview and record review it was determined the facility failed to inform the resident of the risks and benefits of a psychotropic medication for 1 of 5 sampled residents (#37) reviewed for unnecessary medications. This placed residents of risk of being uninformed.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident advance directives were available for 2 of 4 sampled residents #s 46 and 96) reviewed for advance directives. This placed residents at risk for not having their end of life preferences honored.

Inspectors wroteBased on interview and record review it was determined the facility failed to consistently provide restorative services to maintain range of motion for 1 of 1 sampled resident (#96) reviewed for mobility. This placed resident at risk for decreased range of motion.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals for 1 of 2 treatment carts reviewed for medication storage. This placed residents at risk for reduced efficacy of medication.

Inspectors wroteBased on interview and record review it was determined the facility failed to assist a resident with obtaining dentures for 1 of 2 sampled residents (#3) reviewed for dental care. This placed residents at risk for decreased quality of life.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure staff followed the care plan related to toileting for 1 of 1 sampled resident (#7) reviewed for accidents. This placed residents at risk for injuries.

Inspectors wroteBased on record review and interview it was determined the facility failed to complete a discharge summary which included a recapitulation of stay and a final summary of the resident's status for 1 of 3 sampled residents (#1) reviewed for a discharge summary. This placed residents at risk for unmet needs post discharge.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#4) reviewed for medication administration. This placed residents at risk for unmet medication needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to comprehensively assess 8 of 14 sampled residents (#s 25, 26, 32, 36, 52, 55, 57 and 114) reviewed for medications, pressure ulcers, ADLs, pain and nutrition. This placed residents at risk for unassessed needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 5 randomly selected CNAs (#s 15, 23, 24, and 25) reviewed for staff performance reviews. This placed residents at risk for lack of care by competent staff.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was treated in a dignified manner for 1 of 4 sampled residents (#114) reviewed for dignity. This placed residents at risk for lessened quality of life.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess self-administration of a medication for 2 of 3 sampled residents (#s 8 and 26) reviewed for self-administration of medication. This placed residents at risk for unsafe medication administration.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident personal property was identified upon admission, and clothing was retained and accessible for 2 of 4 sampled residents (#s 20 and 57) reviewed for personal property. This place residents at risk for loss of personal property.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a written summary of a baseline care plan was reviewed and provided to residents within 48 hours of admission for 2 of 3 sampled residents (#s 4 and 44) reviewed for care planning. This placed residents at risk for being uninformed about their plan of care.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders and provide bowel medication in a timely manner for 1 of 6 sampled residents (#57) reviewed for medications. This placed residents at risk for medical complications from constipation.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 3 of 3 sampled residents (#s 26, 41 and 57) reviewed for foot care. This placed residents at risk for lack of nail care and infections.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure interventions were in place to prevent smoking related accidents for 1 of 2 sampled residents (#32) reviewed for accidents. This placed residents at risk for smoking-related accidents.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to maintain oxygen equipment and ensure oxygen was administered as ordered for 1 of 2 sampled residents (#46) reviewed for oxygen therapy. This placed residents at risk for increased risk for respiratory failure.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident's ordered pain medication was available and effectively managed the resident's severe pain for 1 of 1 sampled resident (#36) reviewed for pain management. This failure placed residents at risk for unrelieved pain.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide person-centered approaches to behavioral symptoms for 1 of 2 sampled residents (#32) reviewed for psychosocial well-being. This placed residents at risk for unmet psychosocial and mental health needs.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure proper labeling of biologicals for 1 of 2 medication rooms reviewed for medication storage. This placed residents at risk for reduced efficacy of medication.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to protect resident identifiable information and ensure records were accurate for 2 of 4 sampled residents (#s 41 and 42) reviewed for record management and insulin. This placed residents at risk for unauthorized use of their personal information and inaccurate treatment.

Inspectors wroteBased on interview and record review it was determined the facility failed to have a system in place to ensure residents were provided the opportunity to formulate advance directives for 1 of 1 sampled resident (#33) reviewed for advanced directives. This placed residents at risk for not being informed of choices regarding health care decisions.

Inspectors wroteBased on interview and record review it was determined the facility failed to document and conduct a Significant Change MDS assessment for 1 of 6 sampled resident (#38) reviewed for activities of daily living and hospitalizations. This placed residents at risk for unassessed care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a PASRR Level II (Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability) was completed for 1 of 1 sampled resident (#12) reviewed for PASRR. This placed residents at risk for not receiving specialized services.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident's care plan accurately reflected their needs for 1 of 1 sampled resident (#8) reviewed for anticoagulant medication.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide necessary behavioral health care and services for 1 of 1 sampled resident (#12) reviewed for behavioral-emotional needs. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 6 sampled residents (#22) reviewed for medications. This placed residents at risk for adverse medication consequences.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to employ a director of food and nutrition services with the required certification for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to prepare and store foods in a manner to prevent cross contamination and spoilage for 1 of 1 kitchen reviewed for sanitary practices and 1 of 1 resident (#31) reviewed for food service and storage. This placed residents at risk of foodborne illness.